Attachment F - Henrico County

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Dec 14, 2013 (3 years and 6 months ago)

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1




RFP #
13
-
9414
-
4CS


April 1
9
, 2013



REQUEST FOR PROPOSAL

ANNUAL CONTRACT
for
ONLINE PAYMENT SYSTEM FOR SCHOOL FEES

HENRICO COUNTY PUBLIC SCHOOLS


Your firm is invited to submit a proposal to provide

a

web based vendor hosted

online payment system for
s
chool fees

in accordance with the enclosed specifications
. The submittal, consisting of the original proposal
and
seven (7)

additional copies marked,

Online Payment System for School Fees
"
, will be received no later
than
2:30

p.m.,
May 17
, 2013
, by:


IN P
ERSON OR SPECIAL COURIER

U.S. POSTAL SERVICE

County of Henrico

County of Henrico

Department of General Services

Department of General Services

Purchasing Office OR

P O Box 90775

1590 E. Parham Road

Henrico, Virginia 23273
-
0775

Henrico, Virginia 23228


This RFP and any addenda are available on the County of Henrico website at
:
www.co.henrico.va.us

The Bids and Proposals link is listed
under the Henrico Business Section on the home pag
e.


To download the (IFB or RFP), click the link and save the document to your hard drive. To
receive an email copy of this document, please send a request to:
edw@co.henrico.va.us


Time is of the essence and any

proposal received after
2:30
p.m.,
May 17,
201
3
, whether by mail or
otherwise, will be returned unopened. The time of receipt shall be determined by the time clock stamp in the
Purchasing Office, Department of General Services. Proposals shall be placed

in a sealed, opaque envelope,
marked in the lower left
-
hand corner with the RFP number, title, and date and hour proposals are scheduled to
be received. Offerors are responsible for insuring that their proposal is stamped by Purchasing Office
personnel b
y the deadline indicated.



Nothing herein is intended to exclude any responsible firm or in any way restrain or restrict competition. On the
contrary, all responsible firms are encouraged to submit proposals. The County of Henrico reserves the right
to a
ccept or reject any or all proposals submitted.


The awarding authority for this contract
is the
Director of General Services.


Technical questions concerning this Request for
Proposal should be submitted to

Cecelia H. Stowe via email
sto05@co.henrico.va.us

no later than May 1, 2013.



Very truly yours,


Christopher L. Winstead, P.E.

Director of General Services


Cecelia H. Stowe, CPPO, C.P.M.

Purchasing Manager

Sto05@co.henrico.va.us



1590 E. PARHAM ROAD/P O B
OX 90775/HENRICO VA 23273
-
0775

(804) 501
-
5660 FAX (804) 501
-
5693


COMMONWEALTH OF VIRGINIA

C
OUNTY OF
H
ENR
ICO

DEPARTMENT OF GENERAL SERVICES

CHRISTOPHER L. WINSTEAD, P.E.

DIRECTOR


2

REQUEST FOR PROPOSAL

ONLINE PAYMENT SYSTEM FOR SCHOOL FEES


HENRICO COUNTY PUBLIC SCHOOLS



I.

INTRODUCTION
:


The
intent and
purpose of this Request for Proposal (RFP)
,

and the resulting
an
nual
contract
,

is to
obtain the services of
a qualified firm

to

provide
for the furnishing, delivery, installation, and
implementation

of

a

web based vendor hosted

online payment

system

for schools fees

in accordance
with the S
cope of Services

section of t
he solicitation.


II.

BACKGROUND
:



HCPS is a large metropolitan school district with over 48,
5
00 students in 73 schools for the 2013
-
14
school year.
This includes 46 elementary schools, 12 middle schools, 9 high schools, 2 technical
centers, 3 program ce
nters and one pre
school. Each location maintains a separate bank account.

HCPS estimates they conduct over 200,000 transactions
annually in

all schools
with respect to School
Activity Fund Accounting, including cash receipts, disbursements and transfers
, and approximately
125,000 transactions related to
secondary schools
receipt book

system
.

All Elementary schools are
currently using manual receipt books. All Secondary schools are currently using an online teacher
receipt book system developed in hou
se

using File Maker Pro
.


III.

SCOPE OF SERVICES
:


The Successful Offeror shall provide all supervision, labor, material and equipment necessary to
provide the following:


A.


General Requirements


1.

A web based vendor hosted
on
-
line payment system that will al
low parents
/guardians

the
ability to pay student fees by credit card

and other payment
methods (
e.g
.

ACH, eCheck, and
pin
-
less debit cards
)
.


Fees include, but are not limited to
:

Program

f
ee
s
, yearbook, prom, field
trips,
fines,
etc.


2.

The
on
-
line
payment
system must be available 24/7.


3.

All refunds for school fees will
begin at the individual school. The proposed solution must
have the ability to process a refund back to a credit card or other payment method only when
authorized by the school. HCPS wil
l only be responsible to refund the amount of the school
fee and not any transaction or service fees charged by the provider or credit card company.


4.

The Successful O
fferor shall provide a
branded
website at the district level and then broken
out by s
c
h
ool.


5.

A parent/guardian should be able to pay for multiple children at different schools during one
transaction
.


6.

All online payers
should r
eceive an email copy of receipt immediately

to include a transaction
number or confirmation number.


7.

Student data

fields required in the online payment system

include:

the student name, id,
homeroom, grade, and school location. This data
will

be provided in a format suitable for
being imported into an online payment program.





3

8.

The payer will need to enter the stu
dent ID in the online system which will need to validate to
information previously loaded in the online payment
system.



9.

Receipt

data
fields required in the online payment system include: Student name, id,
homeroom, grade and school location, fee name, am
ount, account, date and transaction

or
confirmation

ID.
This data could be provided in a format suitable for being imported into an
online payment program
.


10.

Student

fees paid online will need to be exported in a format suitable for loading into the
receipt

book program
daily
.




11.

Data exchange will
o
ccur daily at a minimum.


12.

It is preferred that
Online payments


be
deposited
in

each
school’s

bank account the business
day following the transaction date. The total deposit information shall be sent to the sc
hool
on the day of deposit
.


13.

Summary
and Detailed
reports should be available

to HCPS

for student

fee history and

activity fee history,
for a specific time range. These reports should minimally include
transaction number, amount and date, name on credit c
ard, student name, id, homeroom,
grade, school location and fees paid.


14.

The
S
uccessful Offeror must provide the
automated credit card payment collection at no cost
to
HCPS
.


Any transaction or convenience fees charged by the Offeror will be paid by the
cus
tomer and will be charged as a separate item to the customer directly.


The amount of any
add on fee will be made clearly known to customers when they use the service so they are
aware of the added cost before completing the transaction.


The Offeror will
notify
HCPS

in
writing at least 60 days prior to making any changes to the fee schedule being charged to
HCPS

customers.


15.

The Successful Offeror must provide capability for HCPS to retrieve the data from their
system at the end of the contract and provide
proof that the data has been removed at no
additional cost to HCPS.


16.

All data that is uploaded to the vendor or created during a payee’s visit to the vendor web site
is the property of HCPS and will remain so indefinitely.


B.

Technical Specifications



1.

Th
e Successful Offeror shall provide a mechanism for allowing payment of school or district
related fees associated with a student. The Successful Offeror’s response will describe in detail
how the solution addresses the following:




Provide a mechanism for
maintaining the fee structure for both district level

(fees all
students are required to pay
)

and school level fees

(those determined by the school
)
.



Maintain the outstanding fees associated with an individual student requiring payment



Maintain general led
ger account information associated with a fee and school



Extracts data received from payments into formats accessible by standard data
management utilities (e.g. Oracle, Excel, Access and Filemaker Pro)



Imports data into the payment system from common data

formats (e.g. comma
delimited, XML)



Provides mechanism to send and receive data between other applications and systems
in the County (e.g. the Student Information System,
Receipt Book system
)


4



Provides a secure platform for ensuring the integrity, privacy

and protection of HCPS
students, staff and parents.


2.

The successful offeror must agree to use the collected information in compliance with all
applicable laws, rules and regulations, including, without limitation, those governing online
privacy and use o
f credit card data (i.e. using credit card information only for purposes
authorized by the cardholder); and IAW applicable Payment Card Industry (PCI) Data Security
Standards.


3.

The Successful Offeror shall specifically state the minimum requirements of the

approved web
browser that will ensure the successful operation of the application. The browsers currently
used internally by HCPS are:




Internet Explorer


version 8 and version 6,



Firefox version 3.6.3
.



Chrome version 19.0 and



Safari version 4.0.5.


The application must support these browsers at a minimum but should show support for other
common browsers that may be in use by parents.


4.

The Successful Offeror shall specifically state the support their tool has for form responses to be
completed on comm
on mobile devices (
e.g.

devices using iOS, Android or Windows 8)


5.

HCPS’ implementation for the Online Payment System is a
web based
vendor hosted solution
.


C.


Training




1.

Detailed training for bookkeepers
for up to 100
and staff as needed

based on
. Technic
al
support for all users of online school payment program.

Offers shall include detailed
information regarding the options available for training (i.e. classroom setting, online demos,
video training, etc.)


D.


Implementation


1.

The system needs to be fully t
ested and operational
no later than

August
1
, 2013



I
V
.

ANTICIPATED SCHEDULE
:


The following represents a tentative outline of the process currently anticipated by the County:


Request for Proposals distributed

April 1
9
, 2013

Advertised in newspaper

April

20, 2013

Receive written proposals

2:30 p.m.,
May 17, 2013

Conduct oral intervi
ews with
Offerors

June 6, 2013

Negotiations
completed




June, 2013

Contract/installation begin
s


July 1, 2013



5

V
.

GENER
AL CONTRACT TERMS AND CONDITIONS
:



A.

Annual Appropriations



It is understood and agreed that the contract resulting from this procurement (“Contract”) shall be
subject to annual appropriations by the County of Henrico, Board of Supervisors. Should the
Board fail to appropriate funds for this Contract, the Contract shall be terminated when existing
funds are exhausted. The successful offeror (“Successful Offeror” or “contractor”) shall not be
entitled to seek redress from the County of Henrico, Virginia

(the “County”) should the Board of
Supervisors fail to make annual appropriations for the Contract.




B.

Award of the Contract


1.

The County reserves the right to reject any or all proposals and to waive any informalities.


2.

The Successful Offeror sha
ll, within fifteen (15) calendar days after Contract documents are
presented for signature, execute and deliver to the Purchasing Office the Contract documents
and any other forms or bonds required by the RFP.


3.

The Contract resulting from this RFP is not a
ssignable.


4.

Upon making an award, or giving notice of intent to award, the County will place appropriate
notice on the public bulletin board located at the following locations:


Purchasing Office




Eastern Government Center

North Run Office Complex


38
20 Nine Mile Road

1590 East Parham Road



Henrico VA

23223

Henrico VA 23228





Henrico Government Center

4301 E. Parham Road

Henrico VA 23228


Notice of award or intent to award may also appear on the Purchasing Office website:
http://www.co.henrico.va.us/genserv



C.

Collusion


By submitting a proposal in response to this Request for Proposal, the Offeror represents that in
the preparation and submission of this proposal, said Offeror did not, either di
rectly or indirectly,
enter into any combination or arrangement with any person, Offeror or corporation or enter into
any agreement, participate in any collusion, or otherwise take any action in the restraint of free,
competitive bidding in violation of th
e Sherman Act (15 U.S.C. § 1 et seq.) or Section 59.1
-
9.1
through 59.1
-
9.17 or Sections 59.1
-
68.6 through 59.1
-
68.8 of the Code of Virginia.


D.

Compensation


The Successful Offeror shall submit a complete itemized invoice on each delivery or service that
is
performed under the Contract. Payment shall be rendered to the Successful Offeror for
satisfactory compliance with the Contract within forty
-
five (45) days after receipt of a proper invoice.



6

E.

Controlling Law and Venue


The Contract will be made, en
tered into, and shall be performed in the County of Henrico, Virginia,
and shall be governed by the applicable laws of the Commonwealth of Virginia without regard to its
conflicts of law principles. Any dispute arising out of the Contract, its interpretat
ions, or its
performance shall be litigated only in the Henrico County General District Court or the Circuit Court
of the County of Henrico, Virginia.


F.

Default


1.

If the Successful Offeror is wholly responsible for a failure to perform the Contract (in
cluding,
but not limited to, failure to make delivery of goods, failure to complete implementation and
installation, and/or if the goods and/or services fail in any way to perform as specified
herein), the County may consider the Successful Offeror to be i
n default. In the event of
default, the County will provide the Successful Offeror with written notice of default, and the
Successful Offeror shall provide a plan to correct said default within 20 calendar days of the
County’s notice of default.


2.

If th
e Successful Offeror fails to cure said default within 20 days, the County, among other
actions, may complete the Contract work through a third party, and the Successful Offeror
shall be responsible for any amount in excess of the Contract price incurred b
y the County
in completing the work to a capability equal to that specified in the Contract.


G.

Discussion of Exceptions to the RFP


This RFP, including but not limited to its venue, termination, and payment schedule provisions,
shall be incorporated by r
eference into the Contract documents as if its provisions were stated
verbatim therein. Therefore, Offerors shall explicitly identify any exception to any provisions of
the RFP in a separate “Exceptions to RFP” section of the proposal so that such exceptio
ns may
be resolved before execution of the Contract. In case of any conflict between the RFP and any
other Contract documents, the RFP shall control unless the Contract documents explicitly
provide otherwise.


H.

Drug
-
Free Workplace to be Maintained by t
he Contractor

(Va. Code § 2.2
-
4312)


1.

During the performance of this Contract, the contractor agrees to (i) provide a drug
-
free
workplace for the contractor’s employees; (ii) post in conspicuous places, available to
employees and applicants for employmen
t, a statement notifying employees that the
unlawful manufacture, sale, distribution, dispensation, possession, or use of a controlled
substance or marijuana is prohibited in the contractor’s workplace and specifying the actions
that will be taken against
employees for violations of such prohibition; (iii) state in all
solicitations or advertisements for employees placed by or on behalf of the contractor that
the contractor maintains a drug
-
free workplace; and (iv) include the provisions of the
foregoing cl
auses in every subcontract or purchase order of over $10,000, so that the
provisions will be binding upon each subcontractor or vendor.


2.

For the purposes of this section,
“drug
-
free workplace”
means a site for the performance of
work done in connection
with a specific contract awarded to a contractor in accordance with
the Virginia Public Procurement Act, the employees of whom are prohibited from engaging
in the unlawful manufacture, sale, distribution, dispensation, possession or use of any
controlled s
ubstance or marijuana during the performance of the contract.



7

I.

Employment Discrimination by Contractor Prohibited


1.

During the performance of this Contract, the contractor agrees as follows (Va. Code § 2.2
-
4311):


(a)

The contractor will not discrimi
nate against any employee or applicant for employment
because of race, religion, color, sex, national origin, age, disability, or other basis
prohibited by state law relating to discrimination in employment, except where there is a
bona fide occupational q
ualification reasonably necessary to the normal operation of
the contractor. The contractor agrees to post in conspicuous places, available to
employees and applicants for employment, notices setting forth the provisions of this
nondiscrimination clause.


(b)

The contractor, in all solicitations or advertisements for employees placed by or on
behalf of the contractor, will state that such contractor is an equal opportunity employer.


(c)


Notices, advertisements and solicitations placed in accordance with fede
ral law, rule or
regulation shall be deemed sufficient for the purpose of meeting the requirements of
this section.


2.

The contractor will include the provisions of the foregoing subparagraphs (a), (b), and (c) in
every subcontract or purchase order of o
ver $10,000, so that the provisions will be binding
upon each subcontractor or vendor.



J.

Employment of Unauthorized Aliens Prohibited




As required by Va. Code § 2.2
-
4311.1, the contractor does not, and shall not during the
performance of this agreemen
t, in the Commonwealth of Virginia knowingly employ an unauthorized
alien as defined in the federal Immigration Reform

and Control

Act of 1986.


K.

Indemnification


The Successful Offeror agrees to indemnify, defend and hold harmless the County (including
Henrico County Public Schools), and the County’s officers, agents and employees from any claims,
damages, suits, actions, liabilities and costs of any kind or nature, including attorneys’ fees, arising
from or caused by the provision of any goods and/or se
rvices, the failure to provide any goods
and/or services and/or the use of any services and/or goods furnished (or made available) by the
Successful Offeror, provided that such liability is not attributable to the County’s sole negligence.



L.

Insurance R
equirements


The Successful Offeror shall maintain insurance to protect itself and the County (including Henrico
County Public Schools) from claims under the Workers' Compensation Act, and from any other
claim for damages for personal injury, including dea
th, and for damages to property which may
arise from the provision of goods and/or services under the Contract, whether such goods and/or
services are provided by the Successful Offeror or by any subcontractor or anyone directly
employed by either of them.

Such insurance shall conform to the Insurance Specifications.
(Attachment A)


M.

No Discrimination against Faith
-
Based Organizations



Henrico County does not discriminate against faith
-
based organizations as that term is defined
in Va. Code § 2.2
-
4343.1
.



8

N.

Offeror's Performance


1.

The Successful Offeror agrees and covenants that its agents and employees shall comply with
all County, State and Federal laws, rules and regulations applicable to the business to be
conducted under the Contract.


2.

The Su
ccessful Offeror shall ensure that its employees shall observe and exercise all
necessary caution and discretion so as to avoid injury to person or damage to property of any
and all kinds.


3.

The Successful Offeror shall cooperate with County officials in

performing the Contract work so
that interference with normal operations will be held to a minimum.




4.

The Successful Offeror shall be an independent contractor and shall not be an employee of the
County.


O.

Ownership of Deliverable and Related Produc
ts


1.

The County shall have all rights, title, and interest in or to all specified or unspecified interim
and final products, work plans, project reports and/or presentations, data, documentation,
computer programs and/or applications, and documentation d
eveloped or generated during
the completion of this project, including, without limitation, unlimited rights to use, duplicate,
modify, or disclose any part thereof, in any manner and for any purpose, and the right to
permit or prohibit any other person, i
ncluding the Successful Offeror, from doing so. To the
extent that the Successful Offeror may be deemed at any time to have any of the foregoing
rights, the Successful Offeror agrees to irrevocably assign and does hereby irrevocably
assign such rights to
the County.


2.

The Successful Offeror is expressly prohibited from receiving additional payments or profit
from the items referred to in this paragraph, other than that which is provided for in the
general terms and conditions of the Contract.


3.

This
shall not preclude Offerors from submitting proposals, which may include innovative
ownership approaches, in the best interest of the County.



P.

Record Retention and Audits


1.

The Successful Offeror shall retain, during the performance of the Contract a
nd for a period of
three years from the completion of the Contract, all records pertaining to the Successful
Offeror’s proposal and any Contract awarded pursuant to this Request for Proposal. Such
records shall include but not be limited to all paid vouch
ers including those for out
-
of
-
pocket
expenses; other reimbursement supported by invoices, including the Successful Offeror’s
copies of periodic estimates for partial payment; ledgers, cancelled checks; deposit slips; bank
statements; journals; Contract am
endments and change orders; insurance documents; payroll
documents; timesheets; memoranda; and correspondence. Such records shall be available to
the County on demand and without advance notice during the Successful Offeror’s normal
working hours.


2.

Cou
nty personnel may perform in
-
progress and post
-
audits of the Successful Offeror’s records
as a result of a Contract awarded pursuant to this Request for Proposals. Files would be
available on demand and without notice during normal working hours.





9

Q.

S
everability


Each paragraph and provision of the Contract is severable from the entire agreement and if any
provision is declared invalid the remaining provisions shall nevertheless remain in effect.


R.

Small, Women
-
Owned and Minority
-
Owned (SWAM) Busines
ses


The County welcomes and encourages the participation of small businesses and businesses
owned by women and minorities in procurement transactions made by the County. The County of
Henrico actively solicits both small business, women
-
owned and minority

(SWAM) businesses to
respond to all Invitations for Bids and Requests for Proposals. All solicitations are posted on the
County’s Internet site at:

http://www.co.henrico.va.us/genserv/purchasi
ng/



S.

Subcontracts


1,

No portion of the work shall be subcontracted without prior written consent of the County. In
the event that the Successful Offeror desires to subcontract some part of the work specified
in the Contract, the Successful Offeror s
hall furnish the County the names, qualifications,
and experience of the proposed subcontractors. The Successful Offeror shall, however,
remain fully liable and responsible for the work to be done by his/her subcontractor(s) and
shall assure compliance wi
th all the requirements of the Contract.


2.

The County encourages the contractor to utilize small, women
-
owned, and minority
-
owned
business enterprises. For assistance in finding subcontractors, contact the Supplier
Relations Coordinator (804
-
501
-
5689) o
r the Virginia Department of Minority Business
Enterprises:


http://www.dmbe.state.va.us/


T.

Taxes


1.

The Successful Offeror shall pay all county, city, state and federal taxes required by law and
resulting from

the work or traceable thereto, under whatever name levied. Said taxes shall not
be in addition to the Contract price between the County and the Successful Offeror, as the
taxes shall be an obligation of the Successful Offeror and not of the County, and t
he County
shall be held harmless for same by the Successful Offeror.


2.

The County is exempt from the payment of federal excise taxes and the payment of State
Sales and Use Tax on all tangible, personal property for its use or consumption. Tax
exemption
certificates will be furnished upon request.


U.

Termination of Contract


1.

The County reserves the right to terminate the Contract immediately in the event that the
Successful Offeror discontinues or abandons operations; is adjudged bankrupt, or is
reorg
anized under any bankruptcy law; or fails to keep in force any required insurance policies
or bonds.


2.

Failure of the Successful Offeror to comply with any section or part of the Contract will be
considered grounds for immediate termination of the Contra
ct by the County.


3.

Notwithstanding anything to the contrary contained in the Contract between the County and the
Successful Offeror, the County may, without prejudice to any other rights it may have,
terminate the Contract for convenience and without ca
use, by giving 30 days’ written notice to
the Successful Offeror.


10



4.

If the County terminates the Contract, the Successful Offeror will be paid by the County for all
scheduled work completed satisfactorily by the Successful Offeror up to the termination dat
e.


V.

County License Requirement


If a business is located in the County, it is unlawful to conduct or engage in that business
without obtaining a business license. If your business is located in the County, include a copy of
your current business licens
e with your proposal submission. If you have any questions,
contact the Business Section, Department of Finance, County of Henrico, telephone (804) 501
-
4310.


W.

Environmental Management


The Successful Offeror shall comply with all applicable federal, state
, and local environmental
regulations.


The Successful Offeror is required to abide by the County’s Environmental Policy
Statement (
http://www.co.henrico.va.us/genserv/pdfs/EnvironmentalPolicyStatement.pdf
), which
emphasizes environmental compliance, pollution prevention, continual improvement, and
conservation.


The Successful Offeror shall b
e properly trained and have any necessary
certifications to carry out environmental responsibilities. The Successful Offeror shall
immediately communicate any environmental concerns or incidents to the appropriate County
staff.


X.

Safety


1.

The Successf
ul Offeror shall comply with and ensure that the Successful Offeror’s
personnel comply with all current applicable local, state and federal policies, regulations
and standards relating to safety and health, including, by way of illustration and not
limitat
ion, the standards of the Virginia Occupational Safety and Health Administration
for the industry. The provisions of all rules and regulations governing safety as adopted
by the Safety and Health Codes Board of the Commonwealth of Virginia and issued by
th
e Department of Labor and Industry under Title 40.1 of the Code of Virginia shall apply
to all work under the Contract. The Successful Offeror shall provide or cause to be
provided all technical expertise, qualified personnel, equipment, tools and material

to
safely accomplish the work specified and performed by the Successful Offeror.


2.

The Successful Offeror shall have, at each location at which the Successful Offeror
provides goods and/or services, a supervisor who is competent, qualified, or authorize
d
on the work site, and who is familiar with policies, regulations and standards applicable
to the work being performed. The supervisor must be capable of identifying existing and
predictable hazards in the surroundings or working conditions which are haza
rdous or
dangerous to employees or the public, and must be capable of ensuring that applicable
safety regulations are complied with, and shall have the authority and responsibility to
take prompt corrective measures, which may include removal of the Succes
sful Offeror’s
personnel from the work site.


3.

In the event the County determines any operations of the Successful Offeror to be
hazardous, the Successful Offeror shall immediately discontinue such operations upon
receipt of either written or oral notice

by the County to discontinue such practice.






11

Y.

Authorization to Transact Business in the Commonwealth



1.

A contractor organized as a stock or nonstock corporation, limited liability company,
business trust, or limited partnership or registered as a

registered limited liability
partnership shall be authorized to transact business in the Commonwealth as a domestic
or foreign business entity if so required by Title 13.1 or Title 50 of the Code of Virginia or
as otherwise required by law.


2.

An Offer
or organized or authorized to transact business in the Commonwealth pursuant
to Title 13.1 or Title 50 of the Code of Virginia must include in its proposal the
identification number issued to it by the State Corporation Commission. (Attachment D)
Any Offer
or that is not required to be authorized to transact business in the
Commonwealth as a foreign business entity under Title 13.1 or Title 50 of the Code of
Virginia or as otherwise required by law shall include in its proposal a statement
describing why the

Offeror is not required to be so authorized.


3.

An Offeror described in subsection 2 that fails to provide the required information shall
not receive an award unless a waiver is granted by the Director of General Services, his
designee, or the County Ma
nager.


4.

Any falsification or misrepresentation contained in the statement submitted by the
Offeror pursuant to Title 13.1 or Title 50 of the Code of Virginia may be cause for
debarment.


5.

Any business entity described in subsection 1 that enters into
a contract with a public
body shall not allow its existence to lapse or allow its certificate of authority or
registration to transact business in the Commonwealth if so required by Title 13.1 or Title
50 of the Code of Virginia to be revoked or cancelled
at any time during the term of the
contract.



Z.

Payment Clauses Required by Va. Code § 2.2
-
4354


Pursuant to Virginia Code § 2.2
-
4354:


1.

The Successful Offeror shall take one of the two following actions within seven days
after receipt of amounts paid to
the Successful Offeror by the County for all or portions of
the goods and/or services provided by a subcontractor: (a) pay the subcontractor for the
proportionate share of the total payment received from the County attributable to the
work performed by th
e subcontractor under that contract; or (b) notify the County and
subcontractor, in writing, of the Successful Offeror’s intention to withhold all or a part of
the subcontractor's payment with the reason for nonpayment.


2.

Pursuant to Virginia Code § 2.2
-
435
4, Successful Offerors that are proprietorships,
partnerships, or corporations shall provide their federal employer identification numbers
to the County. Pursuant to Virginia Code § 2.2
-
4354, Successful Offerors who are
individual contractors shall provide

their social security numbers to the County.


3.

The Successful Offeror shall pay interest to its subcontractors on all amounts owed by
the Successful Offeror that remain unpaid after seven days following receipt by the
Successful Offeror of payment from th
e County for all or portions of goods and/or
services performed by the subcontractors, except for amounts withheld as allowed in
Subparagraph 1. above.


4.

Pursuant to Virginia Code § 2.2
-
4354, unless otherwise provided under the terms of the
Contract interes
t shall accrue at the rate of one percent per month.


12


5.

The Successful Offeror shall include in each of its subcontracts a provision requiring
each subcontractor to include or otherwise be subject to the same payment and interest
requirements with respect to

each lower
-
tier subcontractor.


6.

The Successful Offeror's obligation to pay an interest charge to a subcontractor pursuant
to the payment clause in Virginia Code § 2.2
-
4354 shall not be construed to be an
obligation of the County. A Contract modification s
hall not be made for the purpose of
providing reimbursement for the interest charge. A cost reimbursement claim shall not
include any amount for reimbursement for the interest charge.


AA.

1.

The Contract period shall be from date of award t
hrough a one ye
ar period. The
c
ontract price shall be firm for the Contract period.

2.

After the Contract period, the Contract may be renewed for four (4) additional one
-
year
terms upon written, mutual agreement between the County and the Successful Offeror.
The price

for each subsequent year after the Contract period may not exceed three
percent (3%) above the previous year’s fee and shall remain firm for the renewal year.



BB.

Contact with Students


Offerors shall certify that any of their employees who will provid
e services under the Contract
resulting from this procurement and will be in direct contact with Henrico County Public School
students: (1) has not been convicted of a felony or any offense involving the sexual molestation
or physical or sexual abuse or ra
pe of a child; and (2) such person has not been convicted of a
crime of moral turpitude. Offerors shall cause any of their subVendors to provide the same
certification described herein with regard to the subVendors’ employees.


Henrico County cannot award

a contract to an Offeror that does not c
omplete the
Attachment E

as part of their proposal/submission.


CC.

Conduct


1.

Fraternization between supplier and teachers or students is strictly prohibited.


2.

Use, consumption, and/or possession of any controlled su
bstance, substances
considered to be illegal, and alcohol are strictly prohibited on school grounds.


3.

Cigarette smoking is prohibited on school grounds.


4.

Use of vulgar, suggestive or abusive language or gestures is strictly prohibited on school
grounds.


5.

U
se of radios/stereos or other noise producing equipment shall not be used. No weapons
of any kind are allowed on school grounds.


V
I
.

PROPOSAL

SUBMISSION

REQUIREMENTS
:


A.

The Purchasing Office will not accept oral proposals, nor proposals received by teleph
one, FAX
machine, or other electronic means.


B.

All erasures, interpolations, and other changes in the proposal shall

be signed or initialed by the
Offeror.



13

C.

The Proposal Signature Sheet (
Attachment B
) must accompany any proposal(s) submitted and
be signed b
y an authorized representative of the Offeror. If the Offeror is a firm or corporation,
the Offeror must print the name and title of the individual executing the proposal. All information
requested should be submitted. Failure to submit all information re
quested may result in the
Purchasing Office requiring prompt submission of missing information and/or giving a lowered
evaluation of the proposal.


D.

The proposal, the proposal security, if any, and any other documents required, shall be
enclosed in a sealed

opaque envelope. The envelope containing the proposal shall be sealed
and marked in the lower left
-
hand corner with the number, title, hour, and due date of the
proposal.


E.

The time proposals are received shall be determined by the time clock stamp in t
he Purchasing
Office. Offerors are responsible for insuring that their proposals are stamped by Purchasing
Office personnel by the deadline indicated.


F.

By submitting a proposal in response to this Request for Proposal, the Offeror represents it has
read a
nd understand the Scope of Services and has familiarized itself with all federal, state, and
local laws, ordinances, and rules and regulations that in any manner may affect the cost,
progress, or performance of the Contract work.


G.

The failure or omission o
f any Offeror to receive or examine any form, instrument, addendum, or
other documents or to acquaint itself with conditions existing at the site, shall in no way relieve
any Offeror from any obligations with respect to its proposal or to the Contract.


H.

Tr
ade secrets or proprietary information submitted by an Offeror in response to this Request for
Proposal shall not be subject to public disclosure under the Virginia Freedom of Information Act;
however, the Offeror must invoke the protection of this section

prior to or upon submission of
data or materials, and must identify the data or other materials to be protected and state the
reasons why protection is necessary (Va. Code § 2.2
-
4342.F).
(
Attachment C)


I.

A proposal may be modified or withdrawn by the Offer
or anytime prior to the time and date set
for the receipt of proposals. The Offeror shall notify the Purchasing Office in writing of its
intentions.


1.

If a change in the proposal is requested, the modification must be so worded by the
Offeror as to not r
eveal the original amount of the proposal.


2.

Modified and withdrawn proposals may be resubmitted to the Purchasing Office up to
the time and date set for the receipt of proposals.


3.

No proposal can be withdrawn after the time set for the receipt of proposals

and for one
-
hundred twenty (120) days thereafter.


J.

The County welcomes comments regarding how the proposal documents, scope of services, or
drawings may be improved. Offerors requesting clarification, interpretation of, or improvements
to the proposal ge
neral terms, conditions, scope of services or drawings shall make a written
request which shall reach the Purchasing Office, Division of General Services, at least eight (8)
days prior to the date set for the receipt of proposals. Any changes to the propo
sal shall be in
the form of a written addendum issued by the Purchasing Office and it shall be signed by the
Director of General Services or a duly authorized representative. Each Offeror is responsible
for determining that it has received all addenda iss
ued by the Purchasing Office before
submitting a proposal.



14

K.

All proposals received in the Purchasing Office on time shall be accepted. All late proposals
received by the Purchasing Office shall be returned to the Offeror unopened. Proposals shall
be ope
n to public inspection only after award of the Contract.


VI
I.

PROPOSAL RESPONSE FORMAT
:


A.

Offerors shall submit a written proposal that present the Offeror’s qualifications and
understanding of the work to be performed. Offerors are asked to address each e
valuation
criterion and to be specific in presenting their qualifications. Your proposal should provide all the
information considered pertinent to your qualifications for this project.


B.

The Offeror should include in their proposal the following:




1.

Tab
le of Contents



All Pages are to be numbered




2.

Introduction



Cover Letter
-
on company letterhead, signed by a person with the corporate

authority to enter into contracts in the amount of the proposal.



Proposal Signature Sheet


Attachment B


Propri
etary/Confidential Information


Attachment C


Virginia State Corporation Commission Identification Number


Attachment
D


Direct Contact with Students


Attachment E


References


Attachment G





C.

Executive Summary
-
Response to Scope of Servi
ces


The Offeror should address each
section of the Scope of Services with an indication of the response.
Offerors shall identify any
exceptions, referenced to the paragraph number in a sub section titled “Exceptions”.


Provide responses to the followi
ng questions:


1.

Statement of Qualifications
-

The Offeror should include a company profile that shows the
ability, capacity and skill of the Offeror, their staff, and their employees to perform the
services required within the specified time. Provide resum
es of any staff that will be
assigned to the project to include any subcontractors. Resumes and other information
regarding the professionals (licenses, transcripts, background checks, etc.) to be assigned
to the project may be separated into it’s own sect
ion for confidentiality.


2.

References
-

Provide a minimum of three (3) references

(Attachment G
), which are similar in
size, which could attest to the Offeror's past performance to provide services similar to those
required for the contract. At least one

reference must be a located in Virginia.

Refer
e
nces

from School Districts are preferred.


3.

Provide a preliminary statement of work, detailing your approach to this project. Samples of
progress reports, referenced in the requirements should be included.


4.

Delineate the role that County staff will need to take in the project.


5.

Provide copies of all documents that would need to be signed by the County if awarded the
contract.


6.

Business Health Summary


Please provide responses to the following specific ques
tions:



15

a.

Years in business

b.

Years in business under your present name

c.

Five
-
year history of same product sales

d.

Total installed base:

1.

By number of customers

2.

By seat license count if applicable


e.

Most recent audited financial statements to include a balance she
et and income
statement.


f.

Project and Support Staffing


Please provide responses to the following specific
questions:



1.

Total number of staff:


a.

In the entire company

b.

In software development
,

if applicable

c.

In product sales

d.

In technical support





2.

De
scribe the involvement, if any, of subcontractors in the work


7.

Implementation Plan


a.

Provide a timeline for the implementation of services.

b.

Provide a statement
that the firm has the necessary resources to undertake an
engagement of this magnitude and sha
ll have demonstrated an ability to do the work
required.


8.

Project Management


Please provide a narrative description describing your approach for
providing the requested project management services.


9.

Pricing Schedules
-

Provide detailed costs associa
ted with the implementation, please
summarize the costs on

A
ttachment F


D.

Appendices
-

are optional for Offerors who wish to submit additional material that will clarify
their response.


VIII
.

PROPOSAL

EVALUATION/SELECTION

PROCESS
:


A.

Offerors are to ma
ke written proposals, which present the Offeror's qualifications and
understanding of the work to be performed. Offerors are asked to address each evaluation
criteria and to be specific in presenting their qualifications. Proposals should be as thorough
and detailed as possible so that the County may properly evaluate your capabilities to provide
the required goods/services.



16

B.

Selection of the Successful Offeror will be based upon submission of proposals meeting the
selection criteria. The minimum selec
tion criteria will include:





C.

Selection will be made of two or more Offerors deemed to be fully qualified and best suited
among those submitting proposals. Negotiations shal
l then be conducted with each of the
Offerors so selected. Price shall be considered, but need not be the sole determining factor.
After negotiations have been conducted with each Offeror so selected, the Co
unty shall select
the Offeror
, which, in its op
inion, has made the best proposal, and shall award

the contract to
that Offeror
. Should the County determine in writing and in its sole discretion that only one
Offeror is fully qualified or that one Offeror is clearly more highly qualified that the others

under
consideration, a contract may be negotiated and awarded to that Offeror. The award document
will be a contract incorporating by reference all the requirements, terms and conditions of the
solicitation and the Offeror’s proposal as negotiated.



EVALUATION CRITERIA

WEIGHT

Functional Requirements



Extent to which the proposed solution

satisfies the RFP
r
equirements



Reporting capabilities




Ease of Use




30

Implementation Services



Project
T
eam



Project Approach

to prov
iding services



Project Plan and Schedule



Current Workload and ability to complete required work
within County schedule

15

Experience and Qualifications

of Firm and Staff



Installations (number and size) in k
-
12 environment



Resumes of proposed staff



Financi
al Stability of Firm



References

25

Price

25

Quality of proposal submission/oral presentations

5

TOTAL

100


17



ATTACHMENT A

INSURANCE SPECIFICATIONS


The Successful Vendor shall carry Public Liability Insurance in the amount specified below, including
contractual liability assumed by the Successful Vendor, and shall deliver a Certificate of Insurance from carriers
licensed to do business in the Commonwealth of Virginia. The Certificate shall show the County of Henrico and
Henrico County Public Schools named as an additional insured for the Commercial General Liability coverage.
The coverage shall be provided by a
carrier(s) rated not less than “A
-
“ with a financial rating of at least VII by
A.M. Bests or a rating acceptable to the County. In addition, the insurer shall agree to give the County 30 days
notice of its decision to cancel coverage.


Workers’ Compens
ation



Statutory Virginia Limits

Employers’ Liability Insurance
-

$100,000 for each Accident by employee






$100,000 for each Disease by employee






$500,000 policy limit by Disease


Commercial General Liability
-

Combined Singl
e Limit


$1,000,000 each occurrence including contractual liability for specified agreement

$2,000,000 General Aggregate (other than Products/Completed Operations)

$2,000,000 General Liability
-
Products/Completed Operations

$1,000,000 Personal and Adv
ertising injury

$ 100,000 Fire Damage Legal Liability

Coverage must include Broad Form property damage and (XCU) Explosion, Collapse and Underground
Coverage


Business Automobile Liability



including owned, non
-
owned and hired car coverage


Combined Sin
gle Limit
-

$1,000,000 each accident


NOTE 1:


The commercial general liability insurance shall include contractual liability.


The contract documents
include an indemnification provision(s).


The County makes no representation or warranty as to how the

Vendor’s insurance coverage responds or does not respond.


Insurance coverages that are unresponsive
to the indemnification provision(s) do not limit the Vendor’s responsibilities outlined in the contract
documents.



NOTE 2:


The intent of this insurance

specification is to provide the coverage required and the limits expected for
each type of coverage. With regard to the Business Automobile Liability and Commercial General
Liability, the total amount of coverage can be accomplished through any combinati
on of primary and
excess/umbrella insurance. However, the total insurance protection provided for Commercial General
Liability or for Business Automobile Liability, either individually or in combination with Excess/Umbrella
Liability, must total $3,000,000

per occurrence. This insurance shall apply as primary insurance with
respect to any other insurance or self
-
insurance programs afforded the County of Henrico and Henrico
County Public Schools. This policy shall be endorsed to be primary with respect to
the additional insured.


NOTE 3
:

Title 65.2 of the Code of Virginia requires every employer who regularly employs three or more full
-
time or
part
-
time employees to purchase and maintain workers' compensation insurance. If you do not purchase
a workers’ co
mpensation policy, a signed statement is required documenting that you are in compliance
with Title 65.2 of the Code of Virginia.



7/26/2011


18

Attachment B

SUBMIT THIS FORM WITH PROPOSAL


PROPOSAL SIGNATURE SHEET

Page 1 of 2


My signature certifies that th
e proposal as submitted complies with all requirements specified in this Request for Proposal
(“RFP”).


My signature also certifies that by submitting a proposal in response to this RFP, the Offeror represents that in the
preparation and submission of this

proposal, the Offeror did not, either directly or indirectly, enter into any combination or
arrangement with any person or business entity, or enter into any agreement, participate in any collusion, or otherwise
take any action in the restraining of free,

competitive bidding in violation of the Sherman Act (15 U.S.C. Section 1) or
Sections 59.1
-
9.1 through 59.1
-
9.17 or Sections 59.1
-
68.6 through 59.1
-
68.8 of the Code of Virginia.


I hereby certify that I am authorized to sign as a legal representative for
the business entity submitting this proposal.


LEGAL NAME OF OFFEROR (DO
NOT

USE TRADE NAME):


ADDRESS:



SIGNATURE:

NAME OF PERSON SIGNING (print):

TITLE:

TELEPHONE:

FAX:

E
-
MAIL ADDRESS:

DATE:


PLEASE SPECIFY YOUR
BUSINESS CATEGORY
BY CHECKING

THE APPROPRIATE BOX OR BOXES BELOW.





Please refer to definitions on Page 2 prior to completing. Check all that apply.



MINORITY
-
OWNED BUSINESS

SMALL BUSINESS

WOMEN
-
OWNED BUSINESS


NONE OF THE ABOVE

If certified by the Virginia Minority Business Enterprise (DMBE), provide DMBE certification number and
expiration date. ____________________ NUMBER __________________ DATE


S
UPPLIER REGISTRATION



The County of Henri
co encourages all suppliers interested in doing business with the County to register with
eVA, the Commonwealth of Virginia’s electronic procurement portal,
http://eva.virginia.gov
.


eVA Registered?


YES



NO




19

A
TTACHMENT
B

PAGE
2

OF
2


DEFINITIONS

For the purpose of determining the appropriate business category, the following definitions apply:



Minority
-
owned business
” means a business that is at least 51% owned by one or more mi
nority individuals
who are U.S. citizens or legal resident aliens, or in the case of a corporation, partnership, or limited liability company
or other entity, at least 51% of the equity ownership interest in the corporation, partnership, or limited liabili
ty
company or other entity is owned by one or more minority individuals who are U.S. citizens or legal resident aliens
and both the management and daily business operations are controlled by one or more minority individuals.


As used in the definition of “
minority
-
owned business,
” “
minority individual
” means an individual who is
a citizen of the United States or a legal resident alien and who satisfies one or more of the following
definitions:


1. “
African American
” means a person having origins in any
of the original peoples of Africa and
who is regarded as such by the community of which this person claims to be a part.


2. “
Asian American
” means a person having origins in any of the original peoples of the Far
East, Southeast Asia, the Indian subco
ntinent, or the Pacific Islands, including but not limited to
Japan, China, Vietnam, Samoa, Laos, Cambodia, Taiwan, Northern Mariana, the Philippines, a U.S.
territory of the Pacific, India, Pakistan, Bangladesh, or Sri Lanka and who is regarded as such by

the
community of which this person claims to be a part.


3. “
Hispanic American”

means a person having origins in any of the Spanish
-
speaking peoples of
Mexico, South or Central America, or the Caribbean Islands or other Spanish or Portuguese cultures
and who is regarded as such by the community of which this person claims to be a part.


4. “
Native American
” means a person having origins in any of the original peoples of North
America and who is regarded as such by the community of which this person

claims to be a part or
who is recognized by a tribal organization.



Small business


means a business, independently owned and controlled by one or more individuals who are
U.S. citizens or legal resident aliens, and together with affiliates, has 250 or f
ewer employees, or annual gross
receipts of $10 million or less averaged over the previous three years. One or more of the individual owners shall
control both the management and daily business operations of the small business.



Women
-
owned business


mea
ns a business that is at least 51% owned by one or more women who are U.S.
citizens or legal resident aliens, or in the case of a corporation, partnership, or limited liability company or other
entity, at least 51% of the equity ownership interest is owned

by one or more women who are U.S. citizens or legal
resident aliens, and both the management and daily business operations are controlled by one or more women.




20



ATTACHMENT C


PROPRIETARY/CONFIDENTIAL INFORMATION IDENTIFICATION


NAME OF FIRM/OFFEROR: _
_____________________________


Trade secrets or proprietary information submitted by an
O
fferor shall not be subject to public
disclosure under the Virginia Freedom of Information Act; however, the
O
fferor must invoke the
protections of
Va. Code
§

2.2
-
4342
.
F in writing, either before or at the time the data or other material
is submitted.


The written notice must specifically identify the data or materials to be protected
including the section of the proposal in which it is contained and the page numbers, a
nd state the
reasons why protection is necessary.


The proprietary or trade secret material submitted must be
identified by some distinct method such as highlighting or underlining and must indicate only the
specific words, figures, or paragraphs that cons
titute trade secret or proprietary information.


In
addition, a summary of proprietary information submitted shall be submitted on this form.


The
classification of an entire proposal document, line item prices, and/or total proposal prices as
proprietary
or trade secrets is not acceptable.


If, after being given reasonable time, the
O
fferor
refuses to withdraw such a classification designation, the proposal will be rejected.


SECTION/TITLE

PAGE
NUMBER(S)

REASON(S) FOR WITHHOLDING FROM
DISCLOSURE


































21



ATTACHMENT D


VIRGINIA STATE CORPORATION COMMISSION (SCC)

REGISTRATION INFORMATION





The
B
idder or
O
fferor:


□ is a corporation or other business entity with the following SCC identification number:
________________________________
-
OR
-





is not a corporation, limited liability company, limited partnership, registered limited liability
partnership, or business

trust
-
OR
-




is an out
-
of
-
state business entity that does not regularly and continuously maintain as part of
its ordinary and customary business any employees, agents, offices, facilities, or inventories in
Virginia (not counting any employees or agents

in Virginia who merely solicit orders that
require acceptance outside Virginia before they become contracts, and not counting any
incidental presence of the
B
idder/
O
fferor in Virginia that is needed in order to assemble,
maintain, and repair goods in acco
rdance with the contracts by which such goods were sold
and shipped into Virginia from offer or’s out
-
of
-
state location)
-
OR
-




is an out
-
of
-
state business entity that is including with this bid/proposal an opinion of legal
counsel which accurately and completely discloses the undersigned
B
idder’s/
O
fferor’s current
contacts with Virginia and describes why whose contacts do not c
onstitute the transaction of
business in Virginia within the meaning of §

13.1
-
757 or other similar provisions in Titles 13.1
or 50 of the Code of Virginia.



Please check the following box if you have not checked any of the foregoing options but current
ly
have pending before the SCC an application for authority to transact business in the Commonwealth
of Virginia and wish to be considered for a waiver to allow you to submit the SCC identification
number after the due date for bids/proposals: □


22

ATTACHMEN
T
E


DIRECT CONTACT WITH STUDENTS


BID/PROPOSAL RESPONSE


Name of Bidder/Offeror: ________________________________



Pursuant to
Va. Code

§
22.1
-
296.1
,
prior to awarding a contrac
t for the provision of services that
require the
Vendor
, his employees (or sub
Vendor
s) to have
direct contact with students
, the school
board shall require the
Vendor

and any employee who will have direct contact with students, to
provide certification tha
t (i) he has not been convicted of a felony or any offense involving the sexual
molestation or physical or sexual abuse or rape of a child; and (ii) whether he has been convicted of a
crime of moral turpitude.


Any person making a materially false statemen
t regarding any such offense shall be guilty of a Class
1 misdemeanor and, upon conviction, the fact of such conviction shall be grounds for the revocation
of the
C
ontract to provide such services and, when relevant, the revocation of any license required
to
provide such services.




As part of this submission, I certify that the employees of, or sub
Vendor
s to, the above
mentioned
Vendor

that will be providing services to the School
Board

under the resulting
C
ontract (i) will have not been convicted of a fe
lony or any offense involving the sexual
molestation or physical or sexual abuse or rape of a child; and/or (ii) will not have been
convicted of a crime of moral turpitude. Furthermore, I understand that the duty to certify is
ongoing and extends to future

employees and employees of sub
Vendor
s for the duration of
the
C
ontract.







Signature of Authorized Representative






Printed Name of Authorized Representative






Printed Name of
Vendor

(if different than Representative)



___________________

Date






SUBMIT THIS FORM WITH PROPOSAL







23




Attachment
F

PRICING SUMMARY



Provide an itemized and detailed summary of

all costs associated with
the implementation.


Price per School (72) (leave as zero if there are no incremental costs by school)
:

$
_____
_______


List any additional services and associated
per school
costs if applicable below:



Description:










Price:



________________________________________________________

$___________



________________________________________________________

$__
_________



________________________________________________________

$___________



List all other implementation costs below:



Description:











Price:



________________________________________________________

$___________



_______________________
_________________________________

$___________



________________________________________________________

$___________



________________________________________________________

$___________


TOTAL PRICE:










$____________




List all Fees t
o use a credit card, passed on to the Credit Card Holder, below:



Description:











Price:



________________________________________________________

$___________



________________________________________________________


___________
%







24


ATTACHM
ENT G

SUBMITTAL OF REFERENCES

Reference #1

Name of firm: ______________________________________________________________________

Description of work: _________________________________________________________________

________________________________________
_________________________________________

Name of Contact Person: _________________________________________

Telephone Number: _____________________________________________

Dates work performed: ___________________________________________



Reference #2

Name of firm: ______________________________________________________________________

Description of work: _________________________________________________________________

_________________________________________________________________________________

Na
me of Contact Person: _________________________________________

Telephone Number: _____________________________________________

Dates work performed: ___________________________________________



Reference #3

Name of firm: ________________________________
______________________________________

Description of work: _________________________________________________________________

_________________________________________________________________________________

Name of Contact Person: ________________________
_________________

Telephone Number: _____________________________________________

Dates work performed: ___________________________________________